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+
Thyroid Nodules and Cancer Netee Papneja PGY5
+Objectives
Review Epidemiology of thyroid nodulescancers Approach to thyroid nodules Newer evidence re indications for biopsy Molecular characterization of FNA results Thyroid cancer guidelines
+Epidemiology
Thyroid nodules are very common Palpable nodules
5 of women 1 of men
Ultrasound series 19-67
Autopsy series 37-57
The prevalence of nodules increases with age
Prevalence in women 15-17 times higher than men
ATA guidelines 2009
+Etiology of Benign Nodules
Focal thyroiditis
Benign adenomas ndash follicular and hurthle cell
Thyroid parathyroid thyroglossal cysts
Post surgicalradiation remnant hyperplasia
Rare teratoma lipoma hemangioma
+Thyroid Nodules
Thyroid cancer which occurs in 5ndash15 of nodules
Type Frequency Prognosis
PTC 80 30-year survival 95
Follicular (including Hurthle cell)
10 30-year survival 85
Medullary 5 10-year survival 65
Anaplastic 3 5-year survival 5
Miscellaneous (lymphoma fibrosarcoma SCC teratomas metastatic carcinomas)
1
+Thyroid Cancer ndash Incidence
Incidence of thyroid cancer is increasing 1973 36 per 100000 2009 87 per 100000
However mortality rates have stayed the same
due to actual increase in incidence or increased detection Socioeconomic status and increased access to health care
resources are associated with higher rates of papillary thyroid cancer (US Canada)
+Thyroid Cancer - Incidence
Aim examined whether the density of endocrinologists and general
surgeons use of US were factors associated with increased incidence of thyroid cancer
Methods compared incidence data from SEER database (National
Cancer Institutes Surveillance Epidemiology and End Results) from 1999 to 2009 with the density of endocrinologists and general surgeons
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+
Results The incidence rates were significantly correlated with the density of endocrinologists (r=058 plt00001 for males r=044 p=00031 for females) and the employment of cervical ultrasonography (r=040 p=00091 for males r=036 p=00197 for females)
Conclusions ~ 50 of the DTC epidemic could be explained by
lsquooverdiagnosisrsquo 50 - radiation exposure due to increased use of neck
CT scans chemical exposure andor obesity
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+Thyroid Cancer Risk Factors
Extremes of Age Thyroid nodules in children are twice as likely to be malignant In adults higher rate of malignancy if age gt 60
Sex Malignancy rate 2x higher in men compared to women (8 vs 4)
Family history FHx of a thyroid cancer syndrome (eg familial polyposis Carney
Complex MEN type 2) 10-fold increased risk of thyroid cancer in first degree relatives of
thyroid cancer patients
Uptodate lsquorsquoOverview of thyroid nodule formationrsquorsquo
+Thyroid Cancer Risk Factors
Clinical signs mdash rapid growth fixation of the nodule to surrounding tissues
new onset hoarseness or vocal cord paralysis or the presence of ipsilateral cervical lymphadenopathy
Radiation Explosure most important RF = radiation exposure during childhood ~25 have thyroid nodules
~33 have malignant nodules No evidence that radiation-associated thyroid cancers are
more aggressive than other thyroid cancers
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Objectives
Review Epidemiology of thyroid nodulescancers Approach to thyroid nodules Newer evidence re indications for biopsy Molecular characterization of FNA results Thyroid cancer guidelines
+Epidemiology
Thyroid nodules are very common Palpable nodules
5 of women 1 of men
Ultrasound series 19-67
Autopsy series 37-57
The prevalence of nodules increases with age
Prevalence in women 15-17 times higher than men
ATA guidelines 2009
+Etiology of Benign Nodules
Focal thyroiditis
Benign adenomas ndash follicular and hurthle cell
Thyroid parathyroid thyroglossal cysts
Post surgicalradiation remnant hyperplasia
Rare teratoma lipoma hemangioma
+Thyroid Nodules
Thyroid cancer which occurs in 5ndash15 of nodules
Type Frequency Prognosis
PTC 80 30-year survival 95
Follicular (including Hurthle cell)
10 30-year survival 85
Medullary 5 10-year survival 65
Anaplastic 3 5-year survival 5
Miscellaneous (lymphoma fibrosarcoma SCC teratomas metastatic carcinomas)
1
+Thyroid Cancer ndash Incidence
Incidence of thyroid cancer is increasing 1973 36 per 100000 2009 87 per 100000
However mortality rates have stayed the same
due to actual increase in incidence or increased detection Socioeconomic status and increased access to health care
resources are associated with higher rates of papillary thyroid cancer (US Canada)
+Thyroid Cancer - Incidence
Aim examined whether the density of endocrinologists and general
surgeons use of US were factors associated with increased incidence of thyroid cancer
Methods compared incidence data from SEER database (National
Cancer Institutes Surveillance Epidemiology and End Results) from 1999 to 2009 with the density of endocrinologists and general surgeons
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+
Results The incidence rates were significantly correlated with the density of endocrinologists (r=058 plt00001 for males r=044 p=00031 for females) and the employment of cervical ultrasonography (r=040 p=00091 for males r=036 p=00197 for females)
Conclusions ~ 50 of the DTC epidemic could be explained by
lsquooverdiagnosisrsquo 50 - radiation exposure due to increased use of neck
CT scans chemical exposure andor obesity
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+Thyroid Cancer Risk Factors
Extremes of Age Thyroid nodules in children are twice as likely to be malignant In adults higher rate of malignancy if age gt 60
Sex Malignancy rate 2x higher in men compared to women (8 vs 4)
Family history FHx of a thyroid cancer syndrome (eg familial polyposis Carney
Complex MEN type 2) 10-fold increased risk of thyroid cancer in first degree relatives of
thyroid cancer patients
Uptodate lsquorsquoOverview of thyroid nodule formationrsquorsquo
+Thyroid Cancer Risk Factors
Clinical signs mdash rapid growth fixation of the nodule to surrounding tissues
new onset hoarseness or vocal cord paralysis or the presence of ipsilateral cervical lymphadenopathy
Radiation Explosure most important RF = radiation exposure during childhood ~25 have thyroid nodules
~33 have malignant nodules No evidence that radiation-associated thyroid cancers are
more aggressive than other thyroid cancers
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Epidemiology
Thyroid nodules are very common Palpable nodules
5 of women 1 of men
Ultrasound series 19-67
Autopsy series 37-57
The prevalence of nodules increases with age
Prevalence in women 15-17 times higher than men
ATA guidelines 2009
+Etiology of Benign Nodules
Focal thyroiditis
Benign adenomas ndash follicular and hurthle cell
Thyroid parathyroid thyroglossal cysts
Post surgicalradiation remnant hyperplasia
Rare teratoma lipoma hemangioma
+Thyroid Nodules
Thyroid cancer which occurs in 5ndash15 of nodules
Type Frequency Prognosis
PTC 80 30-year survival 95
Follicular (including Hurthle cell)
10 30-year survival 85
Medullary 5 10-year survival 65
Anaplastic 3 5-year survival 5
Miscellaneous (lymphoma fibrosarcoma SCC teratomas metastatic carcinomas)
1
+Thyroid Cancer ndash Incidence
Incidence of thyroid cancer is increasing 1973 36 per 100000 2009 87 per 100000
However mortality rates have stayed the same
due to actual increase in incidence or increased detection Socioeconomic status and increased access to health care
resources are associated with higher rates of papillary thyroid cancer (US Canada)
+Thyroid Cancer - Incidence
Aim examined whether the density of endocrinologists and general
surgeons use of US were factors associated with increased incidence of thyroid cancer
Methods compared incidence data from SEER database (National
Cancer Institutes Surveillance Epidemiology and End Results) from 1999 to 2009 with the density of endocrinologists and general surgeons
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+
Results The incidence rates were significantly correlated with the density of endocrinologists (r=058 plt00001 for males r=044 p=00031 for females) and the employment of cervical ultrasonography (r=040 p=00091 for males r=036 p=00197 for females)
Conclusions ~ 50 of the DTC epidemic could be explained by
lsquooverdiagnosisrsquo 50 - radiation exposure due to increased use of neck
CT scans chemical exposure andor obesity
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+Thyroid Cancer Risk Factors
Extremes of Age Thyroid nodules in children are twice as likely to be malignant In adults higher rate of malignancy if age gt 60
Sex Malignancy rate 2x higher in men compared to women (8 vs 4)
Family history FHx of a thyroid cancer syndrome (eg familial polyposis Carney
Complex MEN type 2) 10-fold increased risk of thyroid cancer in first degree relatives of
thyroid cancer patients
Uptodate lsquorsquoOverview of thyroid nodule formationrsquorsquo
+Thyroid Cancer Risk Factors
Clinical signs mdash rapid growth fixation of the nodule to surrounding tissues
new onset hoarseness or vocal cord paralysis or the presence of ipsilateral cervical lymphadenopathy
Radiation Explosure most important RF = radiation exposure during childhood ~25 have thyroid nodules
~33 have malignant nodules No evidence that radiation-associated thyroid cancers are
more aggressive than other thyroid cancers
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Etiology of Benign Nodules
Focal thyroiditis
Benign adenomas ndash follicular and hurthle cell
Thyroid parathyroid thyroglossal cysts
Post surgicalradiation remnant hyperplasia
Rare teratoma lipoma hemangioma
+Thyroid Nodules
Thyroid cancer which occurs in 5ndash15 of nodules
Type Frequency Prognosis
PTC 80 30-year survival 95
Follicular (including Hurthle cell)
10 30-year survival 85
Medullary 5 10-year survival 65
Anaplastic 3 5-year survival 5
Miscellaneous (lymphoma fibrosarcoma SCC teratomas metastatic carcinomas)
1
+Thyroid Cancer ndash Incidence
Incidence of thyroid cancer is increasing 1973 36 per 100000 2009 87 per 100000
However mortality rates have stayed the same
due to actual increase in incidence or increased detection Socioeconomic status and increased access to health care
resources are associated with higher rates of papillary thyroid cancer (US Canada)
+Thyroid Cancer - Incidence
Aim examined whether the density of endocrinologists and general
surgeons use of US were factors associated with increased incidence of thyroid cancer
Methods compared incidence data from SEER database (National
Cancer Institutes Surveillance Epidemiology and End Results) from 1999 to 2009 with the density of endocrinologists and general surgeons
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+
Results The incidence rates were significantly correlated with the density of endocrinologists (r=058 plt00001 for males r=044 p=00031 for females) and the employment of cervical ultrasonography (r=040 p=00091 for males r=036 p=00197 for females)
Conclusions ~ 50 of the DTC epidemic could be explained by
lsquooverdiagnosisrsquo 50 - radiation exposure due to increased use of neck
CT scans chemical exposure andor obesity
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+Thyroid Cancer Risk Factors
Extremes of Age Thyroid nodules in children are twice as likely to be malignant In adults higher rate of malignancy if age gt 60
Sex Malignancy rate 2x higher in men compared to women (8 vs 4)
Family history FHx of a thyroid cancer syndrome (eg familial polyposis Carney
Complex MEN type 2) 10-fold increased risk of thyroid cancer in first degree relatives of
thyroid cancer patients
Uptodate lsquorsquoOverview of thyroid nodule formationrsquorsquo
+Thyroid Cancer Risk Factors
Clinical signs mdash rapid growth fixation of the nodule to surrounding tissues
new onset hoarseness or vocal cord paralysis or the presence of ipsilateral cervical lymphadenopathy
Radiation Explosure most important RF = radiation exposure during childhood ~25 have thyroid nodules
~33 have malignant nodules No evidence that radiation-associated thyroid cancers are
more aggressive than other thyroid cancers
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Thyroid Nodules
Thyroid cancer which occurs in 5ndash15 of nodules
Type Frequency Prognosis
PTC 80 30-year survival 95
Follicular (including Hurthle cell)
10 30-year survival 85
Medullary 5 10-year survival 65
Anaplastic 3 5-year survival 5
Miscellaneous (lymphoma fibrosarcoma SCC teratomas metastatic carcinomas)
1
+Thyroid Cancer ndash Incidence
Incidence of thyroid cancer is increasing 1973 36 per 100000 2009 87 per 100000
However mortality rates have stayed the same
due to actual increase in incidence or increased detection Socioeconomic status and increased access to health care
resources are associated with higher rates of papillary thyroid cancer (US Canada)
+Thyroid Cancer - Incidence
Aim examined whether the density of endocrinologists and general
surgeons use of US were factors associated with increased incidence of thyroid cancer
Methods compared incidence data from SEER database (National
Cancer Institutes Surveillance Epidemiology and End Results) from 1999 to 2009 with the density of endocrinologists and general surgeons
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+
Results The incidence rates were significantly correlated with the density of endocrinologists (r=058 plt00001 for males r=044 p=00031 for females) and the employment of cervical ultrasonography (r=040 p=00091 for males r=036 p=00197 for females)
Conclusions ~ 50 of the DTC epidemic could be explained by
lsquooverdiagnosisrsquo 50 - radiation exposure due to increased use of neck
CT scans chemical exposure andor obesity
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+Thyroid Cancer Risk Factors
Extremes of Age Thyroid nodules in children are twice as likely to be malignant In adults higher rate of malignancy if age gt 60
Sex Malignancy rate 2x higher in men compared to women (8 vs 4)
Family history FHx of a thyroid cancer syndrome (eg familial polyposis Carney
Complex MEN type 2) 10-fold increased risk of thyroid cancer in first degree relatives of
thyroid cancer patients
Uptodate lsquorsquoOverview of thyroid nodule formationrsquorsquo
+Thyroid Cancer Risk Factors
Clinical signs mdash rapid growth fixation of the nodule to surrounding tissues
new onset hoarseness or vocal cord paralysis or the presence of ipsilateral cervical lymphadenopathy
Radiation Explosure most important RF = radiation exposure during childhood ~25 have thyroid nodules
~33 have malignant nodules No evidence that radiation-associated thyroid cancers are
more aggressive than other thyroid cancers
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Thyroid Cancer ndash Incidence
Incidence of thyroid cancer is increasing 1973 36 per 100000 2009 87 per 100000
However mortality rates have stayed the same
due to actual increase in incidence or increased detection Socioeconomic status and increased access to health care
resources are associated with higher rates of papillary thyroid cancer (US Canada)
+Thyroid Cancer - Incidence
Aim examined whether the density of endocrinologists and general
surgeons use of US were factors associated with increased incidence of thyroid cancer
Methods compared incidence data from SEER database (National
Cancer Institutes Surveillance Epidemiology and End Results) from 1999 to 2009 with the density of endocrinologists and general surgeons
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+
Results The incidence rates were significantly correlated with the density of endocrinologists (r=058 plt00001 for males r=044 p=00031 for females) and the employment of cervical ultrasonography (r=040 p=00091 for males r=036 p=00197 for females)
Conclusions ~ 50 of the DTC epidemic could be explained by
lsquooverdiagnosisrsquo 50 - radiation exposure due to increased use of neck
CT scans chemical exposure andor obesity
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+Thyroid Cancer Risk Factors
Extremes of Age Thyroid nodules in children are twice as likely to be malignant In adults higher rate of malignancy if age gt 60
Sex Malignancy rate 2x higher in men compared to women (8 vs 4)
Family history FHx of a thyroid cancer syndrome (eg familial polyposis Carney
Complex MEN type 2) 10-fold increased risk of thyroid cancer in first degree relatives of
thyroid cancer patients
Uptodate lsquorsquoOverview of thyroid nodule formationrsquorsquo
+Thyroid Cancer Risk Factors
Clinical signs mdash rapid growth fixation of the nodule to surrounding tissues
new onset hoarseness or vocal cord paralysis or the presence of ipsilateral cervical lymphadenopathy
Radiation Explosure most important RF = radiation exposure during childhood ~25 have thyroid nodules
~33 have malignant nodules No evidence that radiation-associated thyroid cancers are
more aggressive than other thyroid cancers
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Thyroid Cancer - Incidence
Aim examined whether the density of endocrinologists and general
surgeons use of US were factors associated with increased incidence of thyroid cancer
Methods compared incidence data from SEER database (National
Cancer Institutes Surveillance Epidemiology and End Results) from 1999 to 2009 with the density of endocrinologists and general surgeons
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+
Results The incidence rates were significantly correlated with the density of endocrinologists (r=058 plt00001 for males r=044 p=00031 for females) and the employment of cervical ultrasonography (r=040 p=00091 for males r=036 p=00197 for females)
Conclusions ~ 50 of the DTC epidemic could be explained by
lsquooverdiagnosisrsquo 50 - radiation exposure due to increased use of neck
CT scans chemical exposure andor obesity
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+Thyroid Cancer Risk Factors
Extremes of Age Thyroid nodules in children are twice as likely to be malignant In adults higher rate of malignancy if age gt 60
Sex Malignancy rate 2x higher in men compared to women (8 vs 4)
Family history FHx of a thyroid cancer syndrome (eg familial polyposis Carney
Complex MEN type 2) 10-fold increased risk of thyroid cancer in first degree relatives of
thyroid cancer patients
Uptodate lsquorsquoOverview of thyroid nodule formationrsquorsquo
+Thyroid Cancer Risk Factors
Clinical signs mdash rapid growth fixation of the nodule to surrounding tissues
new onset hoarseness or vocal cord paralysis or the presence of ipsilateral cervical lymphadenopathy
Radiation Explosure most important RF = radiation exposure during childhood ~25 have thyroid nodules
~33 have malignant nodules No evidence that radiation-associated thyroid cancers are
more aggressive than other thyroid cancers
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+
Results The incidence rates were significantly correlated with the density of endocrinologists (r=058 plt00001 for males r=044 p=00031 for females) and the employment of cervical ultrasonography (r=040 p=00091 for males r=036 p=00197 for females)
Conclusions ~ 50 of the DTC epidemic could be explained by
lsquooverdiagnosisrsquo 50 - radiation exposure due to increased use of neck
CT scans chemical exposure andor obesity
UdelsmanRampZhangYTheepidemicof thyroid cancer in the United States the role of endocrinologists and ultrasounds Thyroid httpdxdoiorg101089thy2013
+Thyroid Cancer Risk Factors
Extremes of Age Thyroid nodules in children are twice as likely to be malignant In adults higher rate of malignancy if age gt 60
Sex Malignancy rate 2x higher in men compared to women (8 vs 4)
Family history FHx of a thyroid cancer syndrome (eg familial polyposis Carney
Complex MEN type 2) 10-fold increased risk of thyroid cancer in first degree relatives of
thyroid cancer patients
Uptodate lsquorsquoOverview of thyroid nodule formationrsquorsquo
+Thyroid Cancer Risk Factors
Clinical signs mdash rapid growth fixation of the nodule to surrounding tissues
new onset hoarseness or vocal cord paralysis or the presence of ipsilateral cervical lymphadenopathy
Radiation Explosure most important RF = radiation exposure during childhood ~25 have thyroid nodules
~33 have malignant nodules No evidence that radiation-associated thyroid cancers are
more aggressive than other thyroid cancers
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Thyroid Cancer Risk Factors
Extremes of Age Thyroid nodules in children are twice as likely to be malignant In adults higher rate of malignancy if age gt 60
Sex Malignancy rate 2x higher in men compared to women (8 vs 4)
Family history FHx of a thyroid cancer syndrome (eg familial polyposis Carney
Complex MEN type 2) 10-fold increased risk of thyroid cancer in first degree relatives of
thyroid cancer patients
Uptodate lsquorsquoOverview of thyroid nodule formationrsquorsquo
+Thyroid Cancer Risk Factors
Clinical signs mdash rapid growth fixation of the nodule to surrounding tissues
new onset hoarseness or vocal cord paralysis or the presence of ipsilateral cervical lymphadenopathy
Radiation Explosure most important RF = radiation exposure during childhood ~25 have thyroid nodules
~33 have malignant nodules No evidence that radiation-associated thyroid cancers are
more aggressive than other thyroid cancers
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Thyroid Cancer Risk Factors
Clinical signs mdash rapid growth fixation of the nodule to surrounding tissues
new onset hoarseness or vocal cord paralysis or the presence of ipsilateral cervical lymphadenopathy
Radiation Explosure most important RF = radiation exposure during childhood ~25 have thyroid nodules
~33 have malignant nodules No evidence that radiation-associated thyroid cancers are
more aggressive than other thyroid cancers
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Thyroid cancer risk factors
Radiation exposure - potential sources medical uses of radiation (eg childhood malignancies) atomic weapons (eg NagasakiHiroshima Japan 1945) or
nuclear power plant accidents (eg Chernobyl 1986 Fukushima Daiichi nuclear disaster 2011)
ionizing radiation to treat benign conditions of the head and neck in 1950s
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Investigations
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Investigations
Laboratory tests Serum TSH
If low radionuclide thyroid scan Either 123I or 99mTc pertechnetate
Otherwise Further evaluation for possible FNA TSH level correlates to risk of thyroid cancer
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Thyroid Cancer and TSH
TSH (mUL) Prevalence of thyroid cancer ()
lt 04 28
04 ndash 09 37
10 ndash 17 84
18 ndash 55 123
gt 55 297
Boelaert K Horacek J Holder RL et al Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration J Clin Endocrinol Metab 2006 914295
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Investigations
Laboratory tests Serum thyroglobulin (Tg)
Can be elevated in most thyroid diseases Insensitive and nonspecific test for thyroid cancer Not recommended as part of the initial evaluation
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Investigations Serum calcitonin
Screening with calcitonin may detect MTC at an earlier stage (likely present if level gt 100 pgmL)
But also detects C-cell hyperplasia and micromedullary carcinoma (clinical significance uncertain)
ATA Cannot recommend either for or against routine measurement
False-positive results hypercalcemia hypergastrinemia neuroendocrine tumors
renal insufficiency papillary and follicular thyroid carcinomas goiter and chronic autoimmune thyroiditis
prolonged treatment with omeprazole (greater than two to four months) beta-blockers and glucocorticoids
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Ultrasound
Hypoechoic
Increased central vascularity
Incomplete halo
Microcalcifications
Irregular borders
Taller than wide (transverse view)
Suspicious lymph nodes
Hyperechoic
Peripheral vascularity
Complete Halo
Comet-tail
Large coarse calcifications
High Risk Features Low Risk Features
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Central Vascularity
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+ Microcalcifications
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Irregular Borders
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Taller Than Wide
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Comet-tail Artifact
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Investigations
Fine-needle aspiration (FNA) Most accurate and cost effective
Sensitivity 76-98 specificity 71-100 Prior to FNA only 15 of resected nodules were
malignant With FNA malignancy rate of resected nodules gt 50 False positive and non-diagnostic cytology rates lowered
with US guidance
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+ATA FNA Indications
High-risk history History of thyroid cancer in first degree relatives external beam radiation as a child exposure to ionizing radiation in childhood or adolescence prior hemithyroidectomy with discovery of thyroid cancer 18FDG avidity on PET scanning MEN2=FMTC-associated RET protooncogene mutation calcitonin gt100 pg=mL
Suspicious features microcalcifications hypoechoic increased nodular vascularity infiltrative margins taller than wide on transverse view
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Diagnostic Accuracy of the Ultrasonographic Features for Subcentimeter Thyroid Nodules Suggested by the Revised ATA GuidelinesKIM ET AL THYROID Volume 23 Number 12 September 2013
Purpose To analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines
Methods 713 nodules 6-10mm (Yonsei University Korea) Frequencies of US features in benign and malignant nodules
were compared Seven modified guidelines were made based on the revised
ATA guidelines and from multi- variate analysis results
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Modified guidelines
1 excluded lsquolsquoincreased nodular vascularityrsquorsquo
2 included composition criteria and only solid nodules were considered
3 excluded the increased nodular vascularity and included solid
4 included macrocalcification
5 included macrocalcification and excluded lsquolsquoincreased nodular vascularityrsquorsquo
6 included macrocalcification and only solids
7 Included macrocalcifications and excluded increased nodular vascularity
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Results
Solid composition and macrocalcification were significantly associated with malignancy (p=0001 and 0003)
Increased vascularity was not significantly associated with malignant nodules (odds ratio 0729 p = 0212)
Among the eight guidelines the ATA guidelines showed the lowest diagnostic performance (Az = 0616)
Excluding increased vascuarity and including solid composition +- macrocalcification to the suspicious US features of the ATA guidelines improved sensitivity (966 vs 970) specificity (266 vs 429) PPV (483 vs 547) and NPV (917 vs 952) thereby resulting in the highest Az value (diagnostic performance) (Az = 0699 p lt 0001)
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+
Conclusions This study suggests that excluding increased vascularity
and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+
Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics
Results of a Population-Based Study
Rebecca Smith-Bindman MD Paulette Lebda MD Vickie A Feldstein MD Dorra Sellami MD Ruth B Goldstein MD Natasha Brasic MD Chengshi Jin PhD John Kornak PhD
JAMA Intern Med Published online August 26 2013
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics Retrospective case control study
8806 patients with 11618 thyroid US at a UCSF facility from January 2000 - March 2005
patients did not have a diagnosis of thyroid cancer at the time of US
They linked the patients with the California Cancer Registry and identified 105 who were diagnosed with thyroid cancer
The cancer patients were matched with a group of cancer-free control subjects from the same cohort based on factors such as gender age and the year of the ultrasound exam
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Results
Only 3 US nodule characteristics were associated with the risk of thyroid cancermdash microcalcifications (odds ratio [OR] 81 95 CI 38-173) size greater than 2 cm (OR 36 95 CI 17-76) an entirely solid composition (OR 40 95 CI 17-92)
1 characteristic = sensitivity 88 high false-positive rate 44 a low positive likelihood ratio of 20 and 56 biopsies will be performed per cancer diagnosed
2 characteristics = sensitivity 52 FPR 7 the positive likelihood ratio (71) and only 16 biopsies performed per cancer diagnosed
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+
Conclusions Using only + microcalcifications or combination of both gt2cm
AND solid as indications for biopsy estimated risk of cancer in those not biopsied is only ~05
May reduce unnecessary biopsies by 90 20 year survival of DTC is gt97 Ongoing surveillance is unlikely to be beneficial as risk for
cancer remains low at 10 years
Doesnrsquot take into account lymphadenopathy invasion beyond thyoird capsule fHx of Thyroid cancer or radiation history was a retrospective study
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+
Fine Needle Aspiration Results
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Investigations FNA
Risk of cancer ()
Usual managment
Benign 0-3 Clinical fu
Follicular lesion or atypia of undetermined significance
5-15 Repeat FNA
Follicular Neoplasm 15-30 Lobectomy
Suspicious for malignancy 60-75 Thyroidectomy or lobectomy
Non diagnostic 1-4 Repeat FNA -US
Malignant 97-99 Thyroidectomy
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Management of Indeterminate FNA
10 to 40 of FNA specimens are cytologically indeterminate Indeterminate results = Follicular Lesion of Undetermined
Significance (FLUS)Atypia of Undetermined Significance (AUS) and (suspicious for) HuumlrthleFollicular Neoplasm
Risk of malignancy FLUSAtypia 5-15 Follicular Neoplasm 15-30
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+FNA ndash indeterminate results
Repeat FNA with ultrasound guidance Satisfactory specimen in 75 of solid nodules Satisfactory specimen in 50 of cystic nodules
On-site cytologic evaluation may improve yield 7 of nodules continue to be nondiagnostic
(and may still be malignant)
75 to 95 of patients undergo surgery for what is ultimately confirmed to be benign increased morbidity operative risk and excess
cost
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+FNA ndash indeterminate results
Improvement in the assessment of indeterminate FNA results may allow better risk stratification
ATA Recommendation C - Can consider molecular markers to help guide management eg BRAF RAS RETPTC Pax8-PPAR-gamma or galectin-3
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Molecular Markers
Two approaches to the molecular characterization of FNA results that are commercially available in the United States
identification of particular molecular markers of malignancy such as BRAF and RAS mutational status
Use of high density genomic data for molecular classification (an FNA-trained mRNA classifier)
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Veracyte Afirma Gene Classifier
GEC assesses gene expression from mRNA from needle washings during a standard FNA procedure Gene expression is compared against 167 genes Veracyte
has previously identified as characteristic of benign and malignant nodules
Reports the nodule as benign or suspicious
Intended as a rule-out test Analysis most effective in identifying lesions with
indeterminate cytology that are highly likely to be benign therefore avoiding surgery
THYROID Volume 23 Number 2 2013
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Clinical Validity of the Afirma Gene Expression ClassifierA large multi-center (49 sites - 35
academic 65 community) prospective clinical validation study published in NEJM in 2012 ldquoDouble-blindrdquo design
patients and physicians blind to molecular result
Molecular lab blind to surgical pathology diagnosis and pathologists unaware of molecular results
-Alexander EK et al Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology N Engl J Med 2012367705-715
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Afirma Gene Expression Classifier
Results For 265 cytologically indeterminate nodules
overall NPV was 93 Sensitivity = 92 (7 of 85 cancers 8 were incorrectly
identified as benign) Specificity = 52 (48 of benign nodules were
incorrectly identified as suspicious)
The risk of malignancy of a GEC benign result is comparable to that of nodule diagnosed as benign by cytopathology (1)
1 Wang CC et al A Large Multicenter Correlation Study of Thyroid Nodule Cytopathology and Histopathology Thyroid 201121243-251
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Afirma GEC ndash Real life experience
However findings of study were obtained in a trial where protocol and enrollment are tightly managed
Understanding how the Afirma GEC performs in a clinical setting remains unclear until recent study published Oct 2013 in JCEM by Erik K Alexander
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+
Methods analyzed all patients who had Afirma GEC testing at 5
academic centers between 2010 ndash2013 339 patients Results analyzed for pooled test performance impact on
clinical care and site-to-site variation
E K Alexander et al Multicenter Clinical Experience with the Afirma Gene Expression Classifier Journal of Clinical Endocrinology amp Metabolism 2013
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+ TOTAL
GEC Benign
GEC Suspicious
GEC Non-Diagnostic
Total 339 174 (51)
148 (44)
17 (5)6 Lost3 Sx2 repeat GEC2 repeat FNA2 repeat FNA 1 refused further testing
AUSFLUS 165 91 (55) 66 (40)
8 (5)
Follicular Neoplasm
161 79 (49) 73 (45)
9 (6)
Suspicious for Malignancy
13 4 (31) 9 (69) 0
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+ Results 148 Afirma GEC ldquoSuspiciousrdquo
141 of 148 (95) surgery recommended 121 of 148 (82) surgery performed Histopathology Malignant 53 (44)
Number Histopathology Malignant
bullAUSFLUS
bullFollicular Neoplasm
bullSuspicious for Malignancy
bull48
bull65
bull8
bull23 (48)
bull24 (37)
bull6 (75)
-21 PTC1 Follicular1 other
-19 PTC4 Follicular1 Hurthle
-6 Papillary Carcinoma
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+ 174 Afirma GEC ldquoBenignrdquo
4 of 174 surgery recommended (3 FLUS1 SUS) 11 of 174 (6) surgery performed
Histopathology Malignant 111 = 06cm PTC
Initial validation study 38 indeterminate nodules were benign however in this study 51 were benign GEC result
Afirma GEC testing after 1st study only recommended for AUS FLUS andor FN cytology not suspicious
This study 96 cyto indeterminate samples were AUSFLUS andor FN explaining the increased proportion of benign GEC results
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+ Benign Afirma GEC results
Only 71 174 patients (41) had documented followup at a mean of 85 months following GEC testing
1071 ndash clinical exam followup 6171 ndash repeat US 1171 of these patients underwent thyroid surgery (personal
preference or compressive symptoms) 10 11 = benign histologically 111 confirmed cancer (10cm US nodules which proved a
06cm PTC histologically) Summary 171 GEC benign proved cancerous
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+ Clinical Impact
95 of Afirma GEC ldquosuspiciousrdquo nodules were referred for thyroid surgery in comparison to only 2 of Afirma GEC ldquobenignrdquo nodules
in an academic clinical setting a 76 reduction in surgery was observed when the Afirma GEC was applied to patients in whom surgery would otherwise have been typically performed
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+ Results
current standard of care practice $12172 per patient Using GEC $10719
cost savings due to less surgeries GEC test sensitivity was assumed to be 91 This cost analysis states that only 14 of malignant nodules
would be missed by the classifier
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+
The Asuragen miRInform Molecular Panel Panel of molecular tests used to to improve
preoperative cytological diagnostic accuracy for indeterminate thyroid nodules These markers are recommended by the ATA
(recommendation rating of Crdquo)
A rule-in method that is designed to have a high predictive specificity that is a positive test is highly associated with malignant histology
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+The Asuragen miRInform Molecular Panel
17 validated molecular markers to identify mutations with strong associations with papillary and follicular thyroid cancers
These mutations and translocations are found in up to 80 of papillary (BRAF RAS RETPTC) and 70 of follicular (RAS PAX8PPARγ)
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+The Asuragen miRInform Molecular Panel
It is commercially available
No published validation of this method yet
However there is a published experience with the noncommercial use of these markers as prospective predictors of thyroid cancer in FNA samples from academic centers
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Nikiforov YE et alJ Clin Endocrinol Metab 963390ndash3397 Objective
to study the clinical utility of molecular testing of thyroid FNA samples with indeterminate cytology
Design material from 1056 consecutive thyroid FNA samples with
indeterminate cytology was used for prospective molecular analysis and tested for a panel of mutations consisted of BRAF V600E NRAS codon 61 HRAS codon 61 and KRAS codons 1213 point mutations and RETPTC1 RETPTC3 and PAX8PPAR1113088 rearrangements
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Results
Risk of malignancy based on cytology AUSFLUS = 14 FNSFN = 27 SMC =54
Risk of malignancy if + for any mutations in panel AUSFLUS = 88 FNSFN = 87 SMC = 95
SFN = suspicious for follicular neoplasm SMC= suspicious for malignant cellNikiforov YE et al 2011 Impact of mutational testing on the diagnosis and management of patients wit cytologically indeterminate thyroid nodules a prospective analysis of 1056 FNA samples J Clin Endocrinol Metab 963390ndash3397
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+ This method demonstrated an overall specificity of 98
only 2 of benign nodules were positive for a genetic marker
Overall sensitivity of this method is only 60 6 (of FLAUS) and 14 (FN) were negative for these mutations
and proved to be cancer on surgical histology
Clinical utility Consider upfront total thyroidectomy for molecular positive result but initial diagnostic lobectomy is still indicated with mutation-negative specimens
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Costs for Molecular Panel
miRInform Thyroid panel retail price = $2250
Medicare reimbursement for this test is $650 and from private insurers varies up to $950
Steven P Hodak et al Information for Clinicians Commercially Available Molecular Diagnosis Testing in the Evaluation of Thyroid Nodule Fine-Needle Aspiration Specimens THYROID Volume 23 Number 2 2013
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Molecular Panel Cost Analysis
Standard of care $578 and molecular testing $682
molecular testing resulted in decreased diagnostic lobectomies (97 v standard of care 116) while initial total thyroidectomy was more frequent (182 v standard of care 161) molecular testing added a diagnostic cost of $5031 to the cost
of each additional indicated total thyroidectomy bringing the total cost to $16414
However the cumulative cost was still less than the cost of a lobectomy ($7684) followed by completion thyroidectomy ($11954) in the standard-of-care cohort
In sensitivity analysis savings were demonstrated if molecular testing cost was less than $870
Yip L et al 2012 Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies J Clin En- docrinol Metab 971905ndash1912
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Next Generation Sequencing Test(NGST)
ThyroSeq new method with the aim of detecting most point mutations
and small insertions or deletions known to occur in thyroid cancer
targets 12 cancer genes with 284 mutational hot spots
The test made its debut at UPMCUPCI Multidisciplinary Thyroid Center at the University of Pittsburgh
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Next Generation Sequencing Test
Study published 2013
228 thyroid neoplastic and nonneoplastic specimens assessed
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Next Generation Sequencing Test
ThyroSeq DNA assay identified mutations in 19 of 27 of PTC (70) 25 of 30 follicular variant PTCs (83) 3 of 10 poorly differentiated carcinomas (30) 20 of 27 anaplastic (ATCs) (74) 11 of 15 medullary thyroid carcinomas (73)
5 of 83 benign nodules (6) were positive for mutations
Clin Thyroidol 201325288ndash289 Next-Generation Sequencing Has Identified New Oncogenic Mutations in Thyroid Nodules
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Next Generation Sequencing Test
Conclusions Allows testing for multiple mutations with high accuracy
and sensitivity Point mutations were detected in 30 to 83 of specific
types of thyroid cancer and in only 6 of benign thyroid nodules
Discovery of uncommon mutations such as PTEN TP53 PI3KCA and TSHR With the addition of these mutations to those of BRAF RAS and the PAX8PPARg and RETPTC rearrangements 80 of thyroid cancers are now believed to have detectable mutations
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Use Molecular Methods
Experience with these molecular methods remains limited and no test has perfect sensitivity and specificity
The ATA feels that until expert consensus review of existing data (now underway by the ATA Guidelines Task Force) can be completed no evidence-based recommendation for or against the use of these methods can be made
Clinicians are therefore advised to consider the use of these genetic diagnosis methods with appropriate caution
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+Conclusion
Thyroid cancer incidence rates have been increasing worldwide due to increased detection rates from US No associated higher mortality
ATA guidelines may be modified to decrease frequency of FNA done
New molecular methods for indeterminate FNA samples seem to be promising but not available in Canada yet
+
Questions
+
Questions
